Safety and efficiency considerations for the
introduction of electronic ordering in a blood bank.

Abstract:

* The introduction of computerized provider order entry (CPOE)
systems is associated with major changes in work processes.
Implementation strategies need to consider how the technology will
affect and be affected by the organization in which it is being
installed. The aim of this study was to examine the potential effect of
the introduction of a CPOE system on key work processes in a hospital
blood bank by using qualitative data from focus groups, interviews, and
participant observation and quantitative data of telephone
communication. We found that work practices in the blood bank are made
up of a mosaic of collaborative processes underpinned by communication
channels to facilitate safe and efficient work practices. The
introduction of CPOE systems requires consideration of these channels
and of the ways that CPOE may disrupt existing communication processes.
There needs to be high levels of staff preparedness to minimize patient
risk and optimize performance.

Pathology services have been described as the "hidden science
that saves lives." (1) They make an essential contribution to the
effective prevention, detection, and management of disease but are still
widely perceived as a backroom function, (2) with many people unaware of
their vital, ongoing importance.1 There are many signs that this
situation is changing, particularly with the emphasis on the role of
pathology in patient pathways beginning with the selection of the most
appropriate test or investigation onto the interpretation and provision
of clinical advice across many clinical specialties. (2) Information and
communication technology has a critical part to play in this
development. This technology is a central feature of pathology
laboratories, particularly in complex hospital settings reliant on the
efficient management of information for patient care. (3)

The implementation of computerized provider order entry (CPOE)
systems provides a possible foundation for enhancing the role of
pathology services in the patient care process. (4) These systems enable
doctors, and other authorized clinicians to issue orders electronically,
leading to efficient order communication and decision support at the
point of ordering. However, CPOE introduction can also be associated
with important and disruptive changes to laboratory and clinical
professionals' work practices and processes. (5) The planning and
implementation of these systems requires consideration of how the
technology will both affect and be affected by the organization in which
it is being installed. (6) This is of particular importance for
pathology departments, which consist of a diverse range of services,
each with its own unique tasks and requirements. (2)

Pathology services have received limited attention in the research
literature on CPOE, (7) with even less consideration of specific
pathology departments and their particular organizational and technical
features. The blood bank was chosen for study because of the critical
role it has in the safety and quality of patient care. Our aim was to
describe key work processes of laboratory professionals within a
hospital blood bank and examine the potential effect of the introduction
of CPOE systems by using qualitative data from focus groups, interviews,
and participant observation and quantitative data of telephone
communication.

METHODS

Design and Research Setting

The study was carried out in the blood bank of a 600-bed teaching
hospital in Sydney, Australia, which provides a networked blood banking
service throughout a large metropolitan area and is involved in the
investigation of antibodies and transfusion-related issues. The blood
bank has 13 full-time equivalent staff, including 5 scientists and 8
technical officers/assistants. There are also 6 hematologists available
on site. It is part of a pathology service made up of more than 300
staff members covering 6 hospitals within an area health service. In
November 2005, the Cerner Millennium Pathnet (Kansas City, Missouri) was
installed, and in January 2006, PowerChart (version 2004.01; Cerner) was
introduced across the hospital. This new integrated system replaced the
existing laboratory information system, allowing doctors and other
authorized clinicians to electronically place orders for a range of
items including pathology and radiology tests. However, during the
period of this study, the electronic ordering of blood and blood
products from the blood bank had yet to be introduced and was not
expected in the foreseeable future.

The study adopted a formative approach to the research setting and
was conducted for a period of 14 months, from May 2005 to June 2006.
This allowed the research team to examine work process issues and
questions as they arose and to assess their likely implications. (8)
Qualitative data were generated by using focus groups, interviews, and
participant observation. The research was iterative and interactive,
incorporating feedback and validation channels and input from senior
pathology management staff.9 Quantitative data relating to the number
and type of telephone calls received during a period of 1 week (May
5-11, 2005), before the system changeover, were also collected.

Participants and Data Collection

Focus groups.--The study included 2 focus groups made up of 3 and 4
participants. These included 2 hospital scientists and 5 technical
officers who were asked a set of semistructured questions about their
expectations of the new electronic ordering system. Participants were
also asked to outline how the laboratory works and to identify perceived
advantages and disadvantages of the new system and how it would affect
work processes. The 2 focus groups met on the hospital premises, and the
meetings were facilitated by the lead author (A.G.) and were taped and
transcribed. This resulted in 29 pages in A4 format.

Interviews.--The focus groups were followed up with a series of
face-to-face interviews with 8 laboratory staff members conducted by the
lead researcher (A.G.). The 8 interviewees included 2 senior laboratory
managers, 2 hospital scientists, and 4 technical officers. Interviews
were repeated with participants for clarification of issues raised and
to investigate the relevance and validity of emerging themes. Given the
size of the blood bank and the difficulties involved in accessing many
staff members, the study adopted convenience sampling techniques based
on participant availability. (10)

Observations.--Three hours of direct observation of work processes
including 4 sessions lasting 30 to 60 minutes were undertaken as a means
of comprehending and confirming participants' descriptions of their
work processes and any issues they thought relevant. Regular notes were
taken of all observations and interviews and compiled in a
researcher's log with memos noting reflections on the investigation
process. The researcher's log provided an audit trail of the study,
documenting decisions and recording issues for follow-up.

All participants were provided with a letter outlining the study,
its voluntary nature, and the confidentiality of all findings and
participants. The research was approved by the Area Health Service
Research Ethics Committee.

Telephone Communication Logs

Blood bank staff kept their own departmental log of telephone calls
received during a 1-week period from May 5-11, 2005. The log recorded
the time a call was received, the originating ward or location, and the
reason for the call. The log did not record "hang-ups"
(instances where calls were not answered by blood bank staff). Reasons
for calls were categorized by blood bank staff as follows:

2. Wards telephone to enquire about the availability of blood
product or validity of crossmatch.

3. Wards telephone and ask for a fresh blood product to be
dispensed through the hospital Lamson pneumatic air tube (Lamson
Engineering, Regents Park NSW, Australia).

4. Wards telephone and ask for a derivative plasma product (eg,
albumin) to be dispensed.

5. Wards telephone to confirm receipt of product.

6. Other enquiries.

7. Other phone calls (eg, personal).

The total number of phone calls logged for the 1 week (n = 199) was
compared against the total number of calls reported by the hospital
communication data logs for the equivalent month (n = 1841; average, 59
per day). Using these figures, we estimated that the phone log sample
represented 48% of all calls received.

Data Analysis

NVivo 2.0 software (QSR International Pty Ltd, Doncaster,
Australia) was used to assist in the analysis of qualitative data. A
grounded theory approach was applied to identify emergent themes using
participants' own words. Themes were then reported and discussed
with a senior hospital scientist who not only provided a valuable
feedback mechanism to enhance the validity of the findings but also
participated in the discovery and assessment of the emerging themes.9
Microsoft Excel (Microsoft Corporation, Redmond, Washington) was used to
analyze the telephone log data.

RESULTS

Analysis of the qualitative data provided 5 key and recurring
considerations relevant to the introduction of CPOE in a blood bank: (1)
the role of the blood bank; (2) work processes involved in the blood
bank; (3) blood bank interaction with clinical staff; (4) information
management in the blood bank; and (5) the impact of electronic ordering.

The Role of the Blood Bank

Participants explained the role of the blood bank as providing
compatible blood components for patients, along with a range of tests
including blood grouping, antibody screening and identification, and
pretransfusion testing. The blood bank dispenses products provided by
the Red Cross Blood Transfusion Service collected from blood donors. It
uses laboratory testing procedures to ensure that the correct product is
safely provided to clinicians and dispensed to the patient. The
difference between the blood bank and other pathology departments was
described in the following way by the Blood Bank Focus Group on
September 1, 2005: "We in the Blood Bank are putting out a result,
as every other pathology lab does, but we're also dispensing a
product.... [This means] we are interacting at a different level with
the clinical areas."

Work Processes Involved in the Blood Bank

The department performs thousands of tests for blood groups and
antibody screens in a month. Participants explained that although the
blood group test is a fairly simple and straightforward test its
accuracy is of critical importance. The overwhelming majority (around
98%) of antibody screens performed by the blood bank will not detect any
antibodies. This allows the blood bank to dispense standard products to
most people. But for the small percentage of people who do have an
antibody, further (often time-consuming and demanding) testing is
required to identify the antibody and to provide a red cell product that
is not going to be destroyed by the patient's immune system. As a
focus group participant explained, "If you look at it
simplistically, all we have to do is to do a blood group and an antibody
screen and provide product. That's over simplifying it to the max,
but in order for us to do that [safely] we've got very, very
complicated work processes involved ... to try and account for all
possible scenarios where things may go wrong." [Blood Bank Focus
Group, September 1, 2005]

Blood Bank Interaction With Clinical Staff

The blood bank process begins with a prescription from a doctor for
a blood product, which is communicated to the blood bank either by a
transfusion request form, telephone call, or facsimile. Any additional
work required is then performed by the blood bank and the product is
made available. The blood bank will usually await further communication
from the ward asking for the product to be sent. This process relies on
telephone communication: "All our work mostly depends on phone
calls." [Blood Bank Focus Group, September 1, 2005]

"Traditionally, in smaller labs, ward staff will come down to
pick up the blood that's being issued. Here we rely on a Lamson
pneumatic tube system to distribute blood around the hospital. Rather
than dealing with one issue on one occasion we have to receive a phone
call requesting the issue. We then have to go and prepare the blood
product for issue in the Lamson system. We send the product and then we
expect a phone call back from the ward to say that they've received
the product, in case it has gone elsewhere. If we don't get that
phone call we've got to contact them and chase them up. It can be
very time consuming as well." [Blood Bank Focus Group, September 1,
2005]

The Figure provides an illustration of the type of phone calls
received and logged by blood bank staff during a 1-week period between
May 5 and May 11, 2005. The total number of calls logged was 199. Most
calls involved requests to send blood products (n = 42), order blood
products (n = 41), or enquiries about availability (n = 37) and other
matters (n = 36).

Participants in the study confirmed that the blood bank
communication process is heavily reliant on the timely exchange and
confirmation of information between clinical staff in the wards and the
blood bank. Senior blood bank staff explained that this process was so
important to the blood bank process that electronic ordering of blood
and blood products was not expected to proceed until there was
confidence that the new CPOE system was able to safely replicate (indeed
improve on) existing levels of communication. In the course of this
study, the blood bank had also decided to accept only written requests
(which could be faxed) for the issue of blood and blood products, as a
means of ensuring a reliable audit trail in the dispensing process.

Information Management in the Blood Bank

The blood bank has a responsibility to account for all the blood
products that are provided to it by the Red Cross. Participants
described this task as particularly important, not only to guard the
integrity of the blood product and protect against potential
contamination of the patient but also to maintain strict inventory
management and control of products. This task is a good example of the
context within which the blood bank operates. It was described by one
participant in this way:

"... historically, personnel in the blood bank labs have
always been very meticulous and very careful and pedantic, I suppose,
about rules and regulations, etc. But as we've got larger and
larger, it has just been impossible to keep that level of detail in the
checking. We've had to accept that people make mistakes and we try
to [engineer out] mistakes by utilizing technology and equipment."
[Blood Bank Focus Group, September 1, 2005]

Impact of Electronic Ordering

Participants outlined areas where they expected that electronic
ordering would affect the blood bank. The most likely change expected to
occur was a reduction in the number of telephone calls from clinicians
ordering or enquiring about blood products. Participants also thought
that electronic ordering could improve monitoring processes by providing
a better overview of the blood bank workload, particularly what orders
were pending, completed, etc. These changes, in turn, were expected to
improve laboratory efficiency.

The other area of impact was in the area of accuracy and
accountability, which many thought had obvious ramifications for the
quality of service delivered. As one participant explained:

"The accuracy thing is important, because sometimes we've
had situations where our blood product will be received, or even
transfused up in the ward, and the person who called for the
products.... They'll say, 'I said I wanted [a particular
product] ...' and the person who took the phone calls will say,
'no, she said [she] wanted this' and you've only got one
word against the other, whereas if it's ordered electronically,
then we and everyone can see, well this person ordered that. If the
wrong products are issued, then at least they know it's our fault
because we issued the wrong product. It is in black and white what was
ordered."

[Blood Bank Focus Group, September 1, 2005]

COMMENT

The results from this study show that work practices in the blood
bank are made up of a complex mosaic of processes involving
multidisciplinary collaboration between hematologists, laboratory
scientists, technical officers, doctors, and nurses who all form a part
of an interrelated system of patient care. This finding reinforces that
of other researchers in this field who have described the multilayered
and collaborative character of the ordering process (11) and have
strongly recommended that new information systems be designed to
facilitate these collaborative relationships and be supported by
negotiation between different hospital departments. (12) Three areas are
highlighted where CPOE's role can affect (either positively or
negatively) the blood bank's contribution to the safety and
effectiveness of patient care. These are (1) information storage and
retrieval; (2) robust communication channels; and (3) safety and quality
of patient care.

Information Storage and Retrieval

The communication relationship between clinical staff on the wards
and blood bank staff, as revealed in the formal pattern of message
exchange between the two, is designed to enhance patient safety. It
starts with the preparation of the product and then proceeds to the
timely dispatch and receipt of the blood product. In addition to these
tasks, the blood bank has vital patient record and material management
functions. (13) This includes maintaining (1) antibody files that
document reactions that patients have experienced in the course of
previous testing and (2) long-term records of patients with hematologic
disorders and who can have special requirements. One of the features of
CPOE systems is their ability to link to databases containing specific
clinical information and error-prevention software. This has obvious
advantages for the blood bank and its information-intense role. However,
the ability to provide information does not necessarily guarantee that
it will be effectively accessed. Badly designed interfaces (eg,
fragmented information screens that do not provide an overview) can lead
to misinterpretation and have adverse effects on patient care. (14)

Robust Communication Channels

The collaborative effort between staff in the blood bank and the
wards relies very heavily on an information infrastructure that allows
hospital personnel to discuss and decide upon the best application of
care. (15) At present, the telephone plays a major role in this
exchange, as shown in the telephone call sample recorded in the Figure.
This form of communication can be described as a synchronous channel
because the exchange occurs at the same time. The changeover from a
synchronous exchange to an asynchronous one (where a message is posted
on the system) represents an important change in the ordering process.
The advantage of this procedure is that blood bank staff and clinicians
are likely to spend less time on the phone "chasing up"
orders. But for this exchange to work, it requires a confirmation that
the message has been received and that there is a corresponding level of
trust in the information. As in the example of the pneumatic tube
system, the failure to acknowledge receipt of a product may introduce an
added task, that of chasing after the ward for confirmation that the
product has been received.

Safety and Quality of Patient Care

The findings also highlight the key safety and quality
considerations that underpin the blood bank ordering process. The blood
bank, in collaboration with clinical staff, has a responsibility to
ensure that patient details and specimens are correctly labeled, to
avoid the possibility of patient identification error. This has
implications for the integrity of the product and the efficiency with
which the product is dispatched. This, in turn, has major consequences
for patient care, particularly if the dispatch of blood products is not
carried out promptly and efficiently. It is critical, therefore, that
the implementation of new computer applications into blood bank settings
is carried out in line with the existing skills and work of both
laboratory and clinical professionals. (5) Without this attention to
work processes and relationships, there is the possibility that
"workarounds" will be introduced, forcing staff to undertake
ways of achieving things that the system does not readily allow to
happen.

Limitations of This Study

The generalization of these findings to other settings is limited
by the size of the sample and the circumstances that may be peculiar to
the study site. Nevertheless, we believe it is important to undertake
such case studies to identify a number of key laboratory processes that
other blood banks and pathology laboratories are also likely to
confront.

CONCLUSION

The maintenance and enhancement of effective communication channels
between the blood bank staff and ward-based clinical staff, along with
rigorous monitoring procedures, are essential for the safe and effective
implementation of electronic ordering systems. New electronic ordering
systems need to (1) facilitate timely communication between the blood
bank and ward staff; (2) cater to the information management tasks
involved in the blood bank; and (3) optimize the safety and quality
components of the blood bank process. These factors are important to the
design and functioning of these systems. They can also contribute to
ensuring high levels of staff support and preparedness in the face of
changes that may be disruptive and difficult.

This study is part of an Australian Research Council Linkage
Grant-funded project to evaluate the impact of information and
communication technologies on organizational processes and outcomes. It
was carried out in partnership with the New South Wales Health
Department. We would also like to acknowledge the cooperation of blood
bank staff in this study.

References

(1.) The Royal College of Pathologists. Pathology: the hidden
science that saves lives. http://www.rcpath.org/index.asp?PageID = 603.
Accessed January 27, 2006.

(2.) Report of the review of NHS pathology services in England.
Review of NHS Pathology Services in England. http://www.dh.gov.uk.
Accessed August 10, 2006.

(12.) Davidson EJ, Chismar W. Examining the organizational
implications of IT use in hospital-based health care: a case study of
computerized order entry. In: Proceedings from the 32nd Hawaii
International Conference on System Sciences; January 5-8, 1999. Maui,
Hawaii.